In 2011, I was discharged on a Community Treatment Order (CTO) from an eating disorder unit where I has spent the past year under Section. I had become what people often call a ‘revolving door patient‘ as between 2008 and 2011, I had three hospital admissions, two of which lasted for one year. Each time I was discharged, I would lose all the weight I had gained in hospital, and more. But my discharge in 2011 was different. And that was because of the CTO; it saved my life.
CTOs have received a lot of negative publicity since their introduction in 2008. There is contradictory evidence for the effectiveness of CTOs, with some research suggesting they are effective in reducing the number of hospital admissions or days spent in hospital, and other research not. However, other research, most recently, the Independent Review of The Mental Health Act has criticised CTOs and called for a dramatic reduction in their usage and for them to be used in a more targeted way. However, the review did acknowledge that there are some service users who benefit from CTOs and I believe eating disorder patients could be those who benefit.
When on a CTO, you have ‘conditions’ that you must follow otherwise you may be recalled to hospital. So why could eating disorder patients benefit from being on a CTO? The important point is that the conditions of a CTO for an eating disorder patient would include a minimum weight that the patient cannot go below. It is because of this condition that CTOs have the potential to save lives of eating disorder patients. Initially, CTOs can act as deterrent, as the threat of being hospitalised following a certain weight loss can encourage sufferers to maintain their weight. This would result in fewer inpatient admissions and be cost saving to the NHS.
When I was discharged on the CTO, it encouraged me to maintain my weight because I didn’t want to be readmitted. By inhibiting weight loss, it broke the revolving door cycle and I had the time out of hospital to realise that there was more to life than my eating disorder. I was able to start building a life. The more the sufferer can bring into their life, the more likely they are to be able to fight the eating disorder and realise what life can have to offer. By stopping weight loss, the CTO gave me the time to start to change thought processes which is key to recovery.
Revolving door patients are often so stuck in the cycle of losing weight and hospitalisation that they cannot see any other way of life.
But because the CTO can break this cycle, it allows the sufferer to see an alternative to the eating disorder.
Similarly, CTOs can act as a form of preventative recall for those that do need hospitalisation. CTOs are likely to result in recall as an inpatient at a higher weight than if the patient was not under a CTO, due to the conditions of the CTO outlining the weight to be maintained. This would lead to a shorter admission with less damage to health and preventing the ‘anorexic thinking’ that occurs with increasing weight loss. This early detection offered by CTOs is key to helping recovery from anorexia by preventing entrenched and severe anorexic thinking that occurs with increasing weight loss.
It is also important to note that the law on CTOs in England and Wales means that only those who are detained under Section 3 of the Mental Health can be placed on a CTO and this can only occur when they are being discharged from hospital. The law in Scotland is different. In Scotland, a CTO can be implemented in the community, without the need for prior hospital admission and detention under Section 3 of The Mental Health Act. The law in Scotland enabling use of CTOs in the community without the need for prior hospitalisation and detention could be useful in England and Wales with regards to eating disorder patients.
By allowing a CTO to be implemented whilst living in the community (without the need for prior hospital admission), it can prevent the deterioration in health and resultant hospital admission which can be a lengthy and expensive process. If a CTO is implemented in the community, patients are less likely to reach such severe low weights where anorexic thought patterns become entrenched and difficult to change and where hospitalisation is needed. This would increase the chance of recovery and would also be cost-saving and beneficial to the economy.
Early intervention is key to recovery from an eating disorder and CTO implementation in the community can allow this.
To further support the potential benefits of implementing CTOs in the community, a spokeswoman for NHS Grampian said: ‘Eating disorder outpatient treatment in the community has the best longer term outcomes,’ and, in further support, a Scottish Government spokesman said: ‘In Scotland, the majority of people living with eating disorders are treated in the community.’
This is not to say that CTOs are suitable for all eating disorder patients. It is likely that they will work well for some, but not for others. But given that anorexia has the highest mortality rate of all mental illnesses and with limited funding and inpatient bed availability, community alternatives for treatment are essential. Considering the use of CTOs with certain eating disorder patients could be life-saving, as it was for me. Additionally, having the option to implement a CTO in the community could be another life-saving alternative worth considering.
By managing certain eating disorder patients in the community using CTOs, it could help prevent the sufferer becoming dangerously ill, allow greater chance of recovery, and reduce pressures on inpatient beds, funding demands and the economy. England is in a mental health crisis and eating disorders are on the rise. We should be exploring all the options available. CTOs may not be the answer, but they could be an option.
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Rebecca Quinlan was first diagnosed with anorexia in 2008, aged 19. She spent most of the period between 2008-11 in eating disorder units receiving treatment for her anorexia.